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A Short Note on Pseudohallucinations
This is a pre-print version of the following article: Turner M.A.
(2014) ‘A Short Note on Pseudohallucinations’. Psychopathology,
47 (4) 270-273.
DOI: 10.1159/000358065
Abstract
Pseudohallucinations are poorly understood with clinicians
continuing to rely on historical contributions to inform their views.
There have been a number of recent attempts to develop a
phenomenologically adequate theory of psychotic symptoms, yet
the reciprocal dependence between the structure of such theories
and the understanding of pseudohallucinations remains
unexploited. This paper seeks to progress the debate about the
nature of pseudohallucinations whilst simultaneously providing
implicit support for a new two factor of psychotic symptoms by
relating the important historical contributions by Hare and Jaspers
to the contemporary debate about the aetiology of psychotic
symptoms. It will be argued that the focus of Hare and Jaspers on
abnormal experience and vivid imagination have their respective
analogues in recent theories of psychotic symptoms. It will be
suggested, however, that an adequate theory requires a contribution
from both processes and that this implies that there are two types
of pseudohallucinations. The paper implies that the concept of
pseudohallucination is central to relating aetiological to
phenomenological considerations and concludes by drawing out
some of the implications of the proposals for understanding
pseudohallucinations involving insight and complex psychotic
symptoms.
Hare and Abnormal Experience
It is exactly 40 years since Edward Hare published 'A Short Note
on Pseudohallucinations' in the British Journal of Psychiatry in
which he argued that they are 'subjective sensory experiences
which are the consequence of functional psychiatric disorders and
which are interpreted in a non-morbid way by the patient'1. Hare's
account of pseudohallucinations seems straightforward, however,
if pseudohallucinations involve the correct interpretation of
abnormal experience, a fortiori hallucinations must involve the
incorrect interpretation of abnormal experience, and this is more
controversial. In order to understand why, we need to appreciate
the close relationship between Hare's views and recent empiricist
theories of delusions, according to which abnormal experiences
give rise to delusional hypotheses which are not rejected because
they are 'defectively evaluated'2.
The main difficulty with a theory of delusions which relies on
abnormal experience and defective evaluation is that whilst it may
provide a way of distinguishing between those phenomena which
are of interest to psychiatry and those which are not, it cannot
account for how complex psychotic content arises3. This is perhaps
not surprising as the theory was originally formulated to explain
the monosymptomatic delusions, and whilst it is not obviously
implausible to suggest that believing one's spouse is an imposter is
due to the defective evaluation of an abnormal experience, it is
difficult to see how the content of a related but more complex
delusion that one's husband is the son of Adam and Eve4 could be
exclusively experiential. Some empiricists have sought to rely on
cognitive bias to take up the explanatory slack, but the difficulties
with this suggestion are that not all psychotic individuals exhibit
cognitive bias and the approach in any case risks collapsing the
explanation of psychotic symptoms with that of medically
unexplained symptoms5.
In terms of understanding where this relates to
pseudohallucinations, notice that if the only thing standing
between pseudohallucinatory content and a frank psychotic
symptom is a process which does not contribute to content, i.e.
evaluation, then all psychotic content becomes both experiential
and potentially pseudohallucinatory. In other words, Hare's
empiricism, when viewed in a broader context, would appear to be
committed to the view that even the most bizarre psychotic
contents could have pseudohallucinatory counterparts. However,
the fact that David refers to a ‘schizophrenic patient who felt he
had an actual power station inside him, complete with labourers,
machinery, cooling towers, etc., knew it was impossible yet was
sure it was so’6 suggests that Hare's difficulty is likely to relate to
placing too much aetiological emphasis on experience, rather than
the implicit countenancing of complex pseudohallucinations.
The issues are obviously complex, and aetiological considerations
quickly become entangled with those relating to phenomenology
and insight. It is perhaps not surprising, then, that Berrios, whose
work on the subject of pseudohallucinations is amongst the most
thought provoking, decides that the concept is 'irretrievably fuzzy
and needs to be abandoned'7 . However, 'fuzziness' or vagueness is
not necessarily a reason for ceasing to use a concept, especially if,
as we shall see, much of the fuzziness can be dissolved by re-
appraising the historical contributions in light of recent theories of
psychosis. What we require is an understanding of
pseudohallucinations which is underwritten by an adequate theory
of psychotic symptoms, and if Hare and empiricism cannot provide
this, then we will need to look elsewhere.
Jaspers and Vivid Imagination
Before we set out the details of an alternative, we can unravel the
confusion which underlies the search for an understanding of
pseudohallucinations, and indeed of psychotic symptoms more
generally, by examining Jaspers' views, which were expounded
exactly 100 years ago in General Psychopathology and are in
many way the historical antithesis of Hare's. With this in mind,
Jaspers supports 'a clear distinction between sense-phenomena and
the phenomenon of imagery (i.e. between hallucination and
pseudo-hallucination)'8 and conceives of pseudohallucinations, not
like Hare, as sense-phenomena, but rather as a form of ‘vivid
imagery’. Now Jaspers' contribution captures an important strand
of thought about the aetiology of psychotic symptoms, although its
relevance is somewhat obscured by the fact that he drove a
theoretical wedge between pseudohallucinations and hallucinations
which makes it difficult to explain the transition between to two
states - as Jaspers himself may have recognized and Fish9 certainly
did.
The important point, however, is that Jaspers approaches
pseudohallucinations from precisely the opposite direction to Hare,
i.e. 'top down' as opposed to 'bottom up'10). And, it should comes
as no surprise, therefore, that just as Hare's focus on abnormal
experience shows his approach to be related to empiricist theories,
Jaspers focus on the imagination also has an analogue in the recent
literature on the aetiology of psychotic symptoms. Currie and
colleagues have argued, in fact, that psychotic symptoms arise
when 'perception-like imaginings'11 are misidentified due to an
'autonoetic agnosia'. Autonoetic agnosia, which here serves a
similar function to empiricism's 'defective evaluation', essentially
involves an inability to recognise an internally generated event as
such and is more familiarly employed to explain auditory
hallucinations and passivity phenomena.
Currie's proposals lend themselves to a natural account of
pseudohallucinations as Jasperian vivid imagery and, in terms of
explaining frank psychotic symptoms, complex contents cause no
difficulties. As Walton points outs, ‘imagining is... a free,
unregulated activity, subject to no constraints save whim,
happenstance, and the obscure demands of the unconscious....'12.
However, Currie's account is not without its difficulties and we
shall point to just two: first, Currie has no way of accounting for
the obvious role of abnormal experiences in the generation of
psychotic symptoms, most notably somatoparaphrenic symptoms.
A careful analysis of these symptoms suggests in fact that the
imagination constitutes a 'secondary or reparative effort', as
Hundert13, referring to Minkowski, puts it. Currie's second
difficulty is that his theory collapses the distinction between
psychotic symptoms and confabulations at a conceptual level.
Two Types of Pseudohallucinations
On the one hand, we require a theory of psychotic symptoms with
content generating mechanisms which can explain how complex
psychotic symptoms arise; and on the other, we need to
accommodate the close relationship between abnormal experience
and psychotic symptoms. We also require that our theory can give
a natural account of pseudohallucinations, and preferably one
which can respect the insights of both Hare and Jaspers on the
subject. With these and a number of other theoretical constraints in
mind, Turner3 argues that such a theory can be formulated by
retaining abnormal experience as a first factor and replacing the
defective evaluation and/or cognitive bias second factor with
confabulation. Following Johnson14, Turner further argues, and this
is where we see the precise relevance of Jaspers work on
pseudohallucinations, that confabulation involves 'a propensity to
detailed imagination' and defective monitoring.
The advantages of Turner's proposal over rival accounts are
significant and before outlining the implications for our
understanding of pseudohallucinations, we will pause to outline
several of the more obvious ones. First, the new theory allows the
empiricist notion of defective evaluation, to be re-cast as 'defective
monitoring', thereby both avoiding the implications that there is, as
David once put it, 'an insight centre'6 in the brain, whilst at the
same time showing the relevance of defective integrated awareness
to psychosis. Second, the theory opens up a natural account of the
failures of acting and reasoning on delusions (and indeed, of
generation of impossible psychotic contents which David6 drew
attention to) which have troubled empiricist accounts and
threatened their central tenet that delusions are beliefs.
This brings us to pseudohallucinations and to the way in which the
new proposals are able to impose some order on what was
previously 'fuzzy' and demonstrate the importance of the concept
by facilitating a rapprochement between Hare and Jaspers. With
this in mind, what the theory implies is that there may in fact be
two types of pseudohallucinations corresponding to the
experiential and imaginational components of the theory. The first
type would be 'Hare pseudohallucinations' involving content which
is experiential and leading to, for example, rudimentary auditory
and visual phenomena. The second type would be 'Jasperian
pseudohallucinations' involving imaginational content. The further
clarification of the nature of Jasperian pseudohallucinations will
need to accommodate that the imagination is a complex faculty
with both imagistic and propositional capabilities both of which
may be affected by defective monitoring. However, it is imagistic
imaginations that involve 'vivid imagery' and in absence of
defective monitoring these can be equated to Jasperian
pseudohallucinations.
It is important to notice that for reasons set out in detail in Turner3
imagistic and propositional imaginations which are defectively
monitored amount, conceptually, to confabulations, and that
propositional imaginings which are not defectively monitored are
closely related to pseudologia fantastica. The latter involve
imaginations about counterfactual states of affairs which an
individual can either present as merely imaginations, or, for
reasons beyond the scope of this discussion, as true. The issues are
subtle, but the following comments by Fish, although ostensibly
about 'fantastic illusions', bring out the conceptual relationships
between propositional and imagistic imaginations, confabulations
and pseudologia fantastica: 'Professor Fish had a patient who
insisted the during the interview he saw the psychiatrist's head
change into that of a rabbit. This patient was given to exaggeration
and confabulation. He also would invent non-existent puppies and
tell other patients not to tread on the puppy'9.
Insight, Complex Symptoms and 'Hare-Jaspers'
Pseudohallucinations
Clinicians will recall case discussions in which no clear attempt is
made to delineate questions about the characteristics of
pseudohallucinations from questions about insight, and to separate
both from the implicit assumptions about the phenomenological
possibilities related to individual diagnoses. The latter is a highly
complicated matter which will not be discussed in this paper.
However, the postulation of two types of pseudohallucinations,
each with their own distinct aetiology, should serve as a starting
point for preventing contributors talking about two different types
of pseudohallucinations without realizing it. Instead the focus can
shift immediately onto deciding which of the two types of
pseudohallucinations most appropriately captures the
phenomenology of an individual case. Jasperian
pseudohallucinations should 'lack concrete reality and appear in
inner subjective space'8, whereas Hare pseudohallucinations should
be less complex and have more prominent sensory, including
spatial characteristics.
Interesting as such debates promise to be, can we rely on
assumptions about the capabilities of experience and the
imagination and characteristics of their products to distinguish
between pseudohallucinations and hallucinations, especially in
light of the aforementioned nosological issues? Fish implies not
when he refers to 'patients with substantial hallucinations which
occur in outer space, but which they recognize as the result of their
active, vivid imagination'9. Hare goes further when he writes: 'from
a psychiatric view, the experience of a sensation is less important
than the way in which the subject interprets it'1. Hare is arguing
that insight should serve as the final arbiter of the distinction
between pseudohallucinations and hallucinations, and he would
surely be correct if symptom content were entirely experiential.
However, for a theory which holds that most symptoms content is
imaginational matters are not so simple and a reliance on insight
leads hallucinations and delusions to be classified with conceptual
confabulations, imagistic and propositional, respectively.
Perhaps we should accept a degree of misclassification as
individuals with schizophrenia confabulate and at least Hare and
Jasperian pseudohallucinations are correctly classified. The
difficulty, however, comes from the other direction: David's case
with the 'power station' delusion 'knew it was impossible yet was
sure it was so’, and this suggests that if we use insight as the
determining factor, then some complex symptoms will have to be
classified as pseudohallucinations. Fortunately, our two factor
theory can accommodate this if we extend the suggestion that the
processes which give to psychotic symptoms can dissociate from
one another and give rise to their own symptoms. We have already
argued that these will include Hare pseudohallucinations
(abnormal experiences), Jasperian pseudohallucinations (vivid
imaginations) and conceptual confabulations (imagistic and
propositional). However, perhaps it is possible for there to be a
third type of pseudohallucination, a 'Hare-Jaspers'
pseudohallucination, comprising both abnormal experiences and
imaginations without defective monitoring; if so, this would
suggest that concept of pseudohallucination is central to our
understanding of cases involving complex contents in which a
feeling of conviction and a sense of truth come apart.
References
1. Hare EH: A Short Note on Pseudo-Hallucinations. Br J
Psychiatry 1973; 122: 469.
2. Coltheart M, Langdon R, McKay R: Schizophrenia and
Monosymptomatic Delusions. Schizophr Bull 2007; 33 (3): 642-7.
3. Turner MA: Psychosis, Agnosia and Confabulation: An
Alternative Two Factor Account. Cognitive Neuropsych 2014: 19,
2, 116-133.
4. Cutting J: Clinical Psychopathology: Two Worlds – Two Minds
– Two Hemispheres. Oxford: Oxford University Press, 1997.
5. Turner MA: Factitious Disorders: Reformulating the DSM-IV
Diagnostic Criteria. Psychosomatics 2006: 47; 23-3
6. David AS: Insight and Psychosis. Br J Psychiatry 1990: 156;
798-808.
7. Berrios G: The History of Mental Symptoms: Descriptive
Psychopathology Since the Nineteenth Century. Cambridge:
Cambridge University Press, 1996.
8. Jaspers K: General psychopathology: Volumes I. Johns Hopkins
University Press, 1997.
9. Fish F: Clinical Psychopathology: Signs and Symptoms in
Psychiatry. Bristol: John Wright and Sons LTD, 1974.
10. Bayne T, Pacherie E: Bottom-Up or Top-Down: Campbell’s
Rationalist Account of Monothematic Delusions. Philos Psychiatr
Psychol 2004: 11 (1); 1-11.
11. Currie G, Ravenscroft I: Recreative Minds. Oxford: Oxford
University Press, 2002.
12. Walton K: Mimesis as Make-Believe. Cambridge: Harvard
University Press, 1990.
13. Hundert EM: Philosophy, Psychiatry and Neuroscience: Three
Approaches to the Mind. A Synthetic Analysis of the Varieties of
Human Experience. Oxford: Clarendon Press, 1990.
14. Johnson MK, O’ Connor M, Cantor J: Confabulation, Memory
Deficits and Frontal Dysfunction. Brain Cogn 1997: 34; 189-206.
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